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    Claim Form Askari

    Uploaded by

    Tahir
    This document is a claim form for medical reimbursement from an organization. It requests information such as the employee and patient names, age, gender, relationship, contact details, clinic/hospital details, treatment costs, nature of claim, and required supporting documents. The employee must certify the accuracy of the information and understands they will be responsible if any fraud is found. Original receipts and documents are required for reimbursement. Claims older than 90 days may require special approval.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Claim Form Askari

    Uploaded by

    Tahir
    174 views1 page
    This document is a claim form for medical reimbursement from an organization. It requests information such as the employee and patient names, age, gender, relationship, contact details, clinic/hospital details, treatment costs, nature of claim, and required supporting documents. The employee must certify the accuracy of the information and understands they will be responsible if any fraud is found. Original receipts and documents are required for reimbursement. Claims older than 90 days may require special approval.

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    CLAIM FORM ASKARI

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    This document is a claim form for medical reimbursement from an organization. It requests information such as the employee and patient names, age, gender, relationship, contact details, clinic/hospital details, treatment costs, nature of claim, and required supporting documents. The employee must certify the accuracy of the information and understands they will be responsible if any fraud is found. Original receipts and documents are required for reimbursement. Claims older than 90 days may require special approval.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    174 views1 page

    Claim Form Askari

    Uploaded by

    Tahir
    This document is a claim form for medical reimbursement from an organization. It requests information such as the employee and patient names, age, gender, relationship, contact details, clinic/hospital details, treatment costs, nature of claim, and required supporting documents. The employee must certify the accuracy of the information and understands they will be responsible if any fraud is found. Original receipts and documents are required for reimbursement. Claims older than 90 days may require special approval.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 1

    `CLAIM FORM

    (For Medical Reimbursement Claims)

    Organization Name _________________________________________________________________________


    Employee Name ___________________________________________________________ Folio No. ________
    Designation __________________________ Patient`s Name & CNIC _________________________________
    Patient`s Age ______ Relation with Employee ________________________ Gender: ☐ Male ☐ Female

    Employee Contact No. ________________________________ (For Claim Processing Updates)

    CLAIM DETAILS
    Name of Clinic/Hospital and Doctor ______________________________________________________________
    Date of Visit _______________ Consultation Fee (Rs.) ___________ Cost of Medicine (Rs.) ___________
    Cost of Investigations/Lab. Tests/Radiology (Rs.) _________________ Total Cost (Rs.) _____________________
    Doctor sign/stamp and valid PMDC Number: ____________________________ (To Be Filled by Treating Doctor)

    NATURE OF CLAIM: (Check relevant)


    ☐ OPD ☐ HOSPITALIZATION ☐ MATERNITY ☐ DREAD DISEASE ☐ MMC ☐ SPECIALIZED INVESTIGATION

    DOCUMENTS CHECKLIST: Please attach the following and tick ☒ to remember. Photocopies are not acceptable for payment.

     ORIGINAL PRESCRIPTION ON DOCTOR’S LETTERHEAD.


     FRESH PRESCRIPTION EVERY 3-6 MONTHS IN CASE OF DIABETES, HYRERTENSION, HEPATITIS & ASTHMA ETC.
    PHOTOCOPY ACCEPTABLE FOR IN-BETWEEN REFILLS.
     ORIGINAL CONSULTATION FEE RECEIPT.
     ORIGINAL MEDICAL STORE CASH MEMO WITH LICENCE NUMBER.
     VALID PMDC NUMBER OF TREATING DOCTOR IS MANDATORY FOR NON-PANEL CLAIMS.
     ORIGINAL DISCHARGE CARD.
     BIRTH CERTIFICATE ISSUED BY NADRA OR THE UNION COUNCIL.
     DR. ADVICE FOR MEDICINES, TESTS/ INVESTIGATIONS AND THEIR REPORTS.
     IN CASE OF MISSING DOCUMENTS OR WRONG TOTALLING, THE CLAIM WILL BE RETURNED BACK.
     CLAIMS OLDER THAN 90 DAYS ARE TIME BARRED AND MAY NEED SPECIAL APPROVAL.

    I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE. IF FOUND FRAUDULENT, INCOMPLETE OR
    INFLATED, I WILL BE RESPONSIBLE.

    EMPLOYEE’S SIGNATURE ______________________________ Date: ____ /____ /________

    BANK & ACCOUNT NO. (ONLY FOR EFT CLIENTS) ________________________________________

    FORWARDED BY (HR): _______________________________ Date: ____ /____ /________

    AGICO/HLT-007/00 Issue Date: 30-03-2022 Page 1 of 1

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